a client with multiple sclerosis is experiencing scotomas blind spots which are limiting peripheral vision what intervention should the nurse include
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1. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

2. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

3. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).

Correct answer: A

Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.

4. The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate to include in the care plan?

Correct answer: A

Rationale: The correct answer is A: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and reduce shortness of breath in COPD clients. This technique involves inhaling slowly through the nose and exhaling through pursed lips. Choice B is incorrect because a high-fat, low-carbohydrate diet is not recommended for individuals with COPD as it can lead to weight gain and worsen respiratory function. Choice C is incorrect as limiting physical activity can lead to deconditioning and worsen COPD symptoms. Regular, moderate exercise is beneficial for individuals with COPD. Choice D is incorrect as excessive fluid intake can strain the heart in COPD clients. It is important to maintain adequate but not excessive fluid intake to prevent dehydration and maintain optimal lung function.

5. A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client’s dichotomous tendency?

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.

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